What are the recommended management strategies for hypertension?

Hypertension Management Strategies

The recommended management for hypertension includes lifestyle modifications for all patients, with pharmacological therapy initiated when systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg, or when systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with target organ damage, established cardiovascular disease, diabetes, or high cardiovascular risk. 1

Blood Pressure Targets

• General population: Target systolic BP of 120-129 mmHg 1
• Older patients (≥65 years): Target systolic BP of 130-139 mmHg 1
• Very elderly (≥85 years): More lenient target of <140/90 mmHg 1
• High-risk patients (diabetes, CKD, established CVD): Target BP <130/80 mmHg 1
• CKD with eGFR >30 mL/min/1.73 m²: Target systolic BP of 120-129 mmHg 1
• Post-stroke: Target systolic BP of 120-130 mmHg 1

Lifestyle Modifications

All patients with hypertension or high-normal BP should implement:

• Physical activity: 30 minutes of moderate aerobic exercise 5-7 days/week plus resistance training 2-3 times weekly 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) and <80 cm (women) 1
• Dietary modifications:
  • Salt restriction to 5-6 g/day
  • Increased consumption of vegetables, fruits, fish, nuts, unsaturated fatty acids
  • Low consumption of red meat and low-fat dairy products 1
• Alcohol limitation: <14 units/week for men, <8 units/week for women 1
• Smoking cessation 1

These lifestyle modifications can reduce BP by approximately 5 mmHg, which translates to significant reductions in cardiovascular morbidity and mortality 2, 3.

Pharmacological Therapy

First-line Medications

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (e.g., lisinopril) or ARBs
• Calcium channel blockers (e.g., amlodipine) 1, 2

Patient-Specific Considerations

• Black patients: Initial therapy should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 1
• Diabetes with proteinuria: RAS blockers (ACE inhibitors or ARBs) recommended 1
• Heart failure with reduced ejection fraction: Combination of ACE inhibitor/ARB, beta-blocker, diuretic, MRA, and SGLT2 inhibitor 1
• Heart failure with preserved ejection fraction: SGLT2 inhibitors recommended 1

Treatment Algorithm

1. Initial therapy:

   • For BP ≥160/100 mmHg or high CV risk: Consider initial combination therapy with two drugs at low doses 1
   • For most patients: Start with a single agent from first-line options 1, 4, 5

2. Titration and combination:

   • If BP not controlled, add a second agent from a different class 1
   • If still not controlled, add a third agent (typically ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1

3. Resistant hypertension:

   • Add a fourth agent or refer to specialist
   • Consider secondary causes of hypertension 1

Additional Cardiovascular Risk Reduction

• Aspirin 75 mg daily for secondary prevention and primary prevention in patients >50 years with controlled BP (<150/90 mmHg) and 10-year CVD risk ≥20% 1
• Statins for all patients with hypertension complicated by cardiovascular disease and for primary prevention in those with 10-year CVD risk ≥20% 1

Monitoring and Follow-up

• Regular follow-up appointments (typically monthly until target BP is achieved) 1
• Home blood pressure monitoring to detect white coat hypertension and monitor treatment effectiveness 1
• Consider ambulatory blood pressure monitoring when clinic readings show unusual variability 1

Special Situations

Hypertensive Crisis

• Hypertensive emergency (BP >180/120 mmHg with end-organ damage): Requires immediate BP reduction with short-acting titratable IV medications in an intensive care setting 6
• Hypertensive urgency (severe hypertension with minimal or no end-organ damage): Can generally be treated with oral antihypertensives as an outpatient 6

Common Pitfalls to Avoid

• Inadequate BP measurement: Ensure proper technique and equipment for accurate readings
• Therapeutic inertia: Don't delay intensification of therapy when BP targets are not met
• Medication non-adherence: Use once-daily dosing or fixed-dose combinations to improve adherence 1
• Ignoring secondary causes: Consider evaluation for secondary hypertension when there is sudden onset/worsening, resistance to multiple drugs, young age, or clinical clues 1
• Rapid BP reduction in chronic hypertension: Avoid too-rapid lowering of BP, which can lead to organ hypoperfusion

Lowering blood pressure has been consistently shown to reduce cardiovascular morbidity and mortality, with a 10 mmHg reduction in systolic BP decreasing risk of CVD events by approximately 20-30% 2.